Medical Ethics in Exercise Physiology
Larry Birnbaum, PhD., EPC
Associate Professor
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN  55811 

According to Bodenheimer and Grumbach[1], there are four major ethical principles that should be applied by health care providers.  These principles are beneficence, nonmaleficence, autonomy, and justice.  The principle of beneficence dictates that health care providers are obligated to help people in need.  For exercise physiologists, this could be helping patients through stress tests, providing appropriate exercise prescriptions for a variety of clients, guiding MI patients through cardiac rehabilitation, or explaining the potential risks and possible benefits of nutritional supplements to athletes.  In each of these cases, exercise physiologists are helping people in need of their care, and the certified exercise physiologist (EPC) is the most qualified health care provider for these particular services.  It is the EPC who can assure that stress tests are safe and yield the most useful information.  It is the EPC who can assure the safest and most effective exercise prescription for diabetics, cardiac patients, cancer patients, children, the elderly, overweight individuals, and a host of others.  The EPC not only keeps up on research in the field, but can also critically analyze studies and, thus, present accurate information on nutritional supplements.  In this latter capacity, the EPC is only providing accurate information, not making any recommendations unless, of course, the supplement in question could cause harm.  In that case, the EPC is obligated to inform the client of the potential harm.  This is the second ethical principle, nonmaleficence.

Nonmaleficence instructs exercise physiologists to do no harm.  The main message here is safety, which has already been indicated in some of the previous examples.  The EPC must assure that each stress test is conducted in the safest possible manner.  A post-MI patient may be highly motivated to exercise and may have a tendency to exercise too vigorously.  The EPC must help the patient exercise in a safe manner.  This is also true for persons trying to lose weight and even for athletes.  The EPC may only see such clients periodically to assess progress.  While conducting the assessment, the EPC must be cognizant of signs and symptoms of overexertion and instruct the client accordingly.  As indicated above, the use of nutritional supplements is an issue the EPC must address from the perspective of safety.  Indeed, the EPC is compelled to inform clients of the risks if they ask about or are known to use supplements.  While the EPC is responsible for providing accurate information about supplements, clients have the right to decide for themselves whether or not they will use supplements, which invokes the third ethical principle, autonomy.

Autonomy is the right of a person to make his/her own decisions.  Regarding health care, this refers to the right of a competent adult to accept or refuse treatment.  Health care providers must inform clients of the probable consequences of either decision, then respect the client’s choice.  Even if the client initially consents to treatment, s/he may stop treatment at any time.  Sharing this information with exercise physiology clients is typically accomplished with an informed consent document. 

The fourth ethical principle is justice.  Justice requires the fair treatment of all persons.  It may be the most difficult ethical concept to practice due to our biases that are either inherent or develop as we mature.  Hopefully, we all want to treat everyone in a fair manner, and we may think we do just that.  In reality, however, our biases may predispose us to treating some clients unfairly.  How could an exercise physiologist treat clients unfairly?  Preferential treatment of some clients over others is one way.  For example, devoting more time and energy to a young, attractive client versus an older, obese client would violate the concept of justice.  That is not to say that devoting more time to some clients is always wrong.  Some clients require more time because their situation is more demanding and some clients may receive preferential treatment (e.g., get treated ahead of others) because their condition is more critical.  Doing what is just may not always be clear cut, and some may argue that justice like beauty is in the eye of the beholder.  A good guide for practicing justice is the golden rule:  Treat others as you would have them treat you.

These ethical principles are often interrelated.  Nonmaleficence and beneficence may have to both be considered when making a decision that requires balancing of risks and benefits.  The benefits of exercise are numerous[2], but exercise always involves some degree of risk.  The more deconditioned a person is before initiating exercise, the greater the risk.  The EPC must weigh the benefits and risks of exercise on an individual basis and discuss them with each client.  The expertise of the EPC is particularly relevant here to assure the correct “dose” of exercise (mode, intensity, duration, frequency) is prescribed.  Autonomy is also involved because the client has the right to accept or refuse the EPC’s advice, and the EPC must respect that right.  Haranguing the client will not promote the health of the client.  The EPC’s advice must always be given with compassion and understanding of the client’s needs.  If the client chooses to not follow the advice, further discussion may be warranted if it appears the client does not understand the situation and harm will likely occur if the advice is not followed.  The additional discussion would be for the benefit of the client, and as such would occur with compassion and respect for the client.

It is likely that exercise physiologists have been applying these ethical principles in their daily practice.  Surely everyone wants to do what is best for the client, not harm them, respect their informed decisions, and treat everyone fairly.  Yet, it is also likely that situations arise in which all four principles cannot be applied uniformly or ideally.  The EPC is then confronted with a difficult decision.  Nonmaleficence commonly takes precedence in such situations (i.e., if you can’t help them, at least don’t harm them). 
 
References 

1.  Bodenheimer, T.S., Grumbach, K. (2005).  Understanding Health Policy:  A Clinical Approach, 4^th ed.  New York:  McGraw-Hill, p129.

2.  Ehrman, J.K., Gordon, P.M., Visich, P.S., Keteyian, S.J.  (2003).  Clinical Exercise Physiology.  Champaign, IL:  Human Kinetics, pp3-4.

 

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